Provider Demographics
NPI:1174820682
Name:DOMINGUES, MARIA C (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:C
Last Name:DOMINGUES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PAVONIA AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2230
Mailing Address - Country:US
Mailing Address - Phone:954-734-0574
Mailing Address - Fax:
Practice Address - Street 1:1068 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3501
Practice Address - Country:US
Practice Address - Phone:954-734-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00630100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ226486YFCQMedicare PIN